Picky Eating in Children Clinical Approach and Management A/P - PowerPoint PPT Presentation

Picky Eating in Children Clinical Approach and Management A/P Marion Aw & Dr Tan Li Nien Michelle Department of Paediatrics Khoo Teck Puat National University Children’s Medical Institute National University Health System

Overview • Definitions – what do we mean by “picky eating” • Why this is an important topic • Assessment & Management – Classification – Feeding Principles (“Food Rules”) – Red flags and when to refer

Definitions Any problem that negatively affects the process by which parents or caregivers provide Feeding food or supply nourishment to Difficulties their young children Picky Eating Fussiness about eating certain foods and fussy mealtime behaviours Kerzner B. Clinical investigation of feeding difficulties in young children: A practical approach. Clinical Pediatrics July 2009 3

Other terms – feeding related • Neophobia – Rejection of new foods – Normal, protective response – Resolves with repeated exposure (8-10x) • Feeding disorder – Results in substantial organic, nutritional or emotional consequences – Connotes a severe problem

Feeding vs Eating Feeding involves an Eating reflects only the child’s actions 1,2 interaction between the child and the caregiver 1,2 1. Chatoor I, Diagnosis and Treatment of Feeding Disorders in Infants, Toddlers, and Young Children . Washington DC: Zero to Three; 2009. 2. Kedesdy JH, Budd KS. Childhood Feeding Disorders. Baltimore: Paul H Brookes; 1998.

Picky Eaters - why bother ? • Prevalent & Important Issue – Implications for the Child • Nutrition / Growth / Neurocognition – Implications for the Family

Prevalence of Feeding Difficulties: Variability in Estimates Age, Location of Study Prevalence Study Population Carruth et al, 2004 50% 19 to 24 months, US Jin et al, 2009 40% 1 to 6 years, China* Dubois et al, 2007 29% 3 to 6 years, Canada McDermott et al, 2008 28% 2 to 4 years, Australia Jacobi et al, 2003 21% 3 to 6 years, Germany Wright et al, 2007 20% 29 to 33 months, UK 2 to 6 years, China † Li et al, 2001 17% 1. Carruth BR, et al. J Am Diet Assoc. 2004;104:S57-S64; *Shanghai; † Yunnan Province. 2. Jin X, et al. Chinese J Child Healthcare. 2009;17:387-389; 3. Dubois L, et al. Int J Behav Nutr Phys Act. 2007;4:9; 4. McDermott BM, et al. J Dev Behav Pediatr. 2008;29:197-205; 5. Jacobi C, et al. J Am Acad Child Adolesc Psychiatry. 2003;42:76- 84; 6. Wright CM, et al. Pediatrics. 2007;120:e1069-e1075; 7. Li Y, et al. Pediatr Int. 2001;43:651-661.

Asia Pacific Family Medicine 2012;11:5 Singapore Data • Telephone, questionnaire survey (2010) • Children 1-10years of age • Parents/ grandparents / care-givers Age at first presentation of picky eating (n = 370).

Asia Pacific Family Medicine 2012;11:5 Singapore Data Refuse Food Selective with Food Snack Eat very little Prevalence of picky eating and feeding difficulty behaviours.

Consequences – Parental Anxiety • Parents or caregivers who perceived their children as picky eaters were concerned with their physical and mental development. 10

Lower Mental Development Index • Mental development index (MDI) scores of picky eaters 115 were 14 points below 110 healthy eaters 105 MDI score * • Determinants of the 100 * differences were mainly 95 social 90 – Maternal education 85 – Parent-child conflict during Healthy Picky Children feeding eaters eaters with infantile anorexia * P <0.05 vs healthy eaters. Chatoor I, et al. Pediatrics. 2004;113:e440-e447.

Chatoor I. Diagnosis and Treatment Feeding: Interaction of Feeding Disorders in Infants, Toddlers, and Young Children. Washington, DC: Zero to Three; 2009. Feeding Parental resistance with pressure decelerating to eat weight gain Maternal pressure to eat at 1 yr negatively predicted child’s weight at 2 yrs 2 . 2 Pediatrics 2008;121:e164-9

Parenting Feeding Styles Controlling Responsive Neglectful Indulgent Hughes SO, et al. Appetite. 2005

Picky Eating in Children : Clinical Approach 1.Assessment of Growth 2.Assess Nutritional Intake – Total / Type of Calories – Energy expenditure 3. Indentify the Feeding Issue – Nutrition & Behaviour / Interaction

Diagnostic Approach: Picking Eating Assess Calorie Intake Sufficient Insufficient • “Picky Eater” • Type of calories consumed • Limited Appetite • 4 Main Food groups • Selective  Dairy • Fear of Feeding  Cereals / whole grains  Meat (Protein) • Chronic Medical Illness  Fruit / Vegetables

Classification Child Limited Appetite Selective Intake Fear of Feeding Misperceived Misperceived (Neophobia) Misperceived pain (colic) Energetic Infant pattern Mildly selective (>15 foods) Apathetic (Neglect) Highly selective Older child (choking) Organic Organic Organic Structural Causes of pain e.g. Delayed Development Gastrointestinal Dysphagia Esophagitis Cardiorespiratory Autism Disordered motility Neurological Visceral hyperalgesia Metabolic Tube feeding

“Picky Eater” - Parental Misperception - • Child is small but achieving satisfactory growth based on mid-parental height • Parent believes child’s appetite is limited when it is appropriate • Excessive parental concern may lead to coercive feeding methods that adversely affect the child

Parental Misperception: Management • Allay parental fears about nutritional inadequacy • Educate Parent – Expected Growth and Nutrition – Feeding principles, & applying them consistently – Important not to force feed

Kerzner B. Clin Pediatr. 2009 Feeding Principles 1. Feed to encourage hunger – 3 meals + 2 snacks, min. eating/drinking between meals 2. Limit length of meal times (30min) 3. Avoid distractions – Feed in a high chair/at table; time-out if behv. disruptive 4. Serve age-appropriate foods 5. Tolerate age-appropriate mess 6. Encourage self-feeding 7. Consistently offer new foods 8. Maintain a neutral attitude during meals

Selective Intake • Mild to Severe (< or > 15 foods) • Refuses specific foods because of taste, texture, smell, or appearance • Moderate-Severe – Rejects complete class of foods – Nutritionally at risk – Visibly anxious if asked to eat aversive foods – Sensory difficulties maybe present

Summary: Feeding Difficulties Increasing severity Family Severe Mild Physician eg, picky Decreasing prevalence or Paediatrician Feeding team Oral-motor specialist and/or Gastroenterologist Dietitian

Summary: Classification Caregiver Child Feeding style Limited Appetite Selective Intake Fear of Feeding Responsive Misperceived Misperceived Misperceived pain (colic) (neophobia) Controlling Energetic Infant pattern Mildly selective (Picky) Indulgent Apathetic Older child (choking) Highly selective Neglectful Organic Organic Organic Causes of pain e.g. Structural Delayed Development Esophagitis Gastrointestinal Dysphagia Disordered motility Cardiorespiratory Autism Visceral hyperalgesia Neural Tube feeding Metabolic Every child and caregiver is influenced by the feeding experience

Summary: Management 1. Assessment of Growth 2. Assessment of Intake (total / type of calories) Diagnose the “Type of Picky Eating” 3. 4. Refer if red flags present 5. Nutritional Support & Intervention - Feeding Principles/ Structure Meals 6. Parental/ Care-give Interaction 23

Nutritional Intervention Ways to increase Oral Intake 1.Feeding schedule that encourages hunger • Feed 3 hour intervals • ~5 - 6 feeds / day (main meals + snacks) 2.Build anchor foods into the diet • 4 main food groups 3.Supplements if needed • High calorie drink • Multi-vitamins